When Less Is More
Studies are finding that aggressive treatment, such as extensive surgery, radiation or chemotherapy, is not always necessary for cancer patients to get good results.
By Alexandra Goho
Photo © iStockphoto / PhotografiaBasica
When it comes to cancer care, patients often assume the more treatment they have, the better off they will be. Exhibit A: breast cancer. In recent years, an increasing number of women with early stage breast cancer have chosen to have a mastectomy—and even a double mastectomy—over a lumpectomy followed by radiation. Yet as their doctors may explain to them, clinical trials have not found that choosing the mastectomy will reduce their risk of dying of breast cancer. Earlier this year, a large retrospective study not only confirmed those findings, but it also suggested that, for a subset of women at least, less surgery might actually be more effective.
The breast cancer study, which appeared in the April 1 issue of Cancer, is not unique. Just in the past few years, researchers have found a number of instances in which less treatment can actually improve a patient’s prospects. As a result, the idea of “less is more” is gaining ground in cancer care.
“It’s an important trend right now,” says Shelley Hwang, the chief of breast surgery at the Duke Cancer Institute in Durham, N.C., who led the study. “Before we knew that there were many different kinds of [cancer], we would treat everyone as though they had the worst kind of disease because we didn’t know any better.” Now, she says, many doctors and patients are aware that they don’t need to pull out all the stops for every type or subtype of cancer to get a good result.
Efforts to reduce the extent of surgery, the amount of chemotherapy or the duration of radiation are being driven, in part, by concerns over the side effects of these cancer treatments. A better understanding of the biology of different subtypes of cancer and new tests that can determine which patients might benefit from more aggressive treatment and which should do well with less are playing a role as well. In concert with the rising cost of health care, these advances are focusing more attention on the need for patients to weigh the risks and benefits of different approaches when deciding what’s best when it comes to their treatment.
Breast Surgery Revisited
When Hwang first noticed the rate of mastectomy was going up, particularly among young, affluent and well-educated women, she became alarmed. "It felt like a throwback to the day when mastectomy was the only choice,” she says. “The fact that more educated and health-literate women are choosing to do something that is probably counter to what their physicians are recommending made me wonder if these women were on to something.” Could there be a subset of women with early stage breast cancer who in fact do better with a mastectomy?
“We’re adding additional radiation risk and we’re adding cost without improving the outcome.”
To answer that question, Hwang and her colleagues identified more than 112,000 women in the California Cancer Registry who had been diagnosed with stage I or II breast cancer from 1990 through 2004, and then followed them for at least five years. The researchers found that, overall, the women who chose lumpectomy and radiation did as well as or better than those who had a mastectomy. Women over age 50 with hormone-sensitive tumors benefited most. They were 13 percent less likely to die of breast cancer within five years of their diagnosis than were those who had a mastectomy.
Isabelle Bedrosian, a surgical oncologist at the University of Texas M. D. Anderson Cancer Center in Houston, cautions that the study looked back at what the women had chosen, which means it doesn’t carry as much statistical weight as a forward-looking clinical trial. Still, she says the important take-home message is that women with early stage breast cancer who choose a lumpectomy over mastectomy are making as good a choice as those who opt for a mastectomy. “You don’t have to be radical to achieve a good result,” she says.
The Price of Radiation
The long-term side effects of radiation—such as increased risk of cardiovascular disease and secondary cancers—have pushed radiologists to explore whether shorter courses of treatment or different types of radiation might be as effective as the traditional longer courses. At the American Society of Clinical Oncology meeting in May, radiation oncologist Jeffrey Bradley from the Washington University School of Medicine in St. Louis presented findings from one of these trials. As he reported, his research group found that patients with stage III non–small cell lung cancer who received the standard dose of radiation had a better outcome than those who received a higher dose.